Step 2 CS assesses the following skills:. Patient-centered communication: You achieve this by building rapport with the patients, listening to them, showing interest in them, expressing empathy when needed, using effective history taking skills (such as using a good balance of open and closed questions, transitions, signposting, and summaries), as well as manifesting interest in them non-verbally (such maintaining an engaged posture and good eye contact). Clinical reasoning: This includes data collection and data analysis. Data collection manifests through your history taking (focused history, driven by a differential), physical exam (focused exam), and through your clinical note (more on that later). Spoken English. Tips regarding history taking. You will have 15 total minutes for the patient encounter (history and exam).
If you finish sooner, you may exit the exam room, but you cannot reenter if you realize you missed some information. Before you enter the patient’s room, you will be provided with vitals and chief complaint.
Use 30-60 seconds to read this information. Write down 2-3 possible diagnoses, and a brief organizational plan. This will help you focus your history. During the interview, do not be too rigid about your initial diagnoses. You should be able to reject them if they do not fit with the patient’s history.
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Anchoring on a specific diagnosis can lead to missing important elements which could suggest alternate possible diagnoses. In addition to the above, be prepared to answer potential patient questions.
Finally, wrap up the patient interview by sharing what you think might be going on and some of the tests that you will order. You are expected to behave as if you were an intern; do not defer decision-making to others (so avoid statements like “I will discuss with my attending and decide what to do.”). You are not expected (nor will you have the time) to do a complete history; your history taking should be centered around the chief complaint. Use a focused Review of Systems. For some cases, you are expected to assist the patient with making decisions and/or with disease or problem management.
In these cases, use your Shared Decision Making Skills and/or counseling skills (the cases will provide specific directions). If you encounter a reserved (unemotional) or upset patient, remember that this is by design.
Continue to engage the patient despite their difficult attitude. One of the best ways to do this is to describe your observation and ask them about it: “I see you are angry, would you like to talk about it?”, or “You seem quiet, is something bothering you?”. If you encounter a patient who uses drugs, alcohol, or tobacco, you will not have time to counsel them on each issue, although you should address them directly. One possible way to do this is to say supportive words such as “I’d like to spend more time with you to discuss (insert topic). Will you come back in 3-4 weeks so we can discuss it then?”. The exam will also include one or two phone cases, where a patient or a patient’s relative calls you with certain symptoms. Take a focused but thorough history.
Express empathy and use patient-centered communication skills. Decide if the patient’s concern can be addressed over the phone or if the patient needs to come in to clinic or ER to be seen in person. In general, if the patient expresses pain, fever, wound redness or discharge after a procedure or surgery, then they likely need to be seen in person and examined. When in doubt, ask the patient to come in to be seen. If you think that the patient needs to be seen in person, do not let them talk you out of it (such as by saying it is too late at night, or that transportation is difficult- this is likely a distractor). Apologize for the inconvenience, explain to them your differential and why it is important to be assessed in person.
Tips regarding physical examination:. Request patient permission before the exam. Clean your hands before and after the exam.
Patients will be wearing gowns and will have a drape on their lap. Ask for permission before you expose a body part and only expose them to the extent that is necessary.
Do not forget to use the drape. You do not have time for a complete physical exam. Perform an exam that is focused on the chief complaint and your differential. Your choice of exam maneuvers will be used as one of the criteria to assess your clinical reasoning. Expect to find positive physical exam findings, take them into consideration when you formulate your differential. Female patients will be wearing bras.
You may ask them to loosen or move it if needed, but do not have them remove the bra. You can examine a body part that the patient says hurts. Be gentle, and do not poke too hard (and apologize or say something nice as you do it). DO NOT repeat a painful exam maneuver. Always examine a patient directly on skin; Never examine a patient through the gown or drape. If you recline the examination table, extend the leg rests for the patient.
You CANNOT do the following: rectal, pelvic, genitourinary, inguinal hernia, female breast, or corneal reflex examinations. If you believe one or more of these examinations are indicated, include them in your proposed diagnostic work-up when you write your note. Tips regarding note writing. You will have 10 minutes to write your note. If you finish your patient encounter in less than 15 minutes, the extra time will be added to your note writing time (the total activity lasts 25 minutes).
Write your note in narrative format. Even though the step 2 CS guide published by the NBME says that the note can be written in bulleted list format, we highly recommend that you write in narrative format. Do not make up history or exam findings.
Only write information that you personally obtained. Do not use abbreviations that are ambiguous or unclear.
A list of accepted abbreviations can be found on page 13 of the. Describe any pertinent positive or negative history or physical exam findings:. For example, if the patient has chest pain and CAD is on your differential, then your history should list the presence or absence of risk factors. As an example, you should say “the patient has no prior history of cardiovascular disease, hypertension, diabetes or hyperlipidemia” rather than saying “his past medical history is negative”. Likewise, you would say “there is no family history of cardiovascular disease or premature death” rather than “family history is non-contributory.”. If a patient is presenting with right knee pain, your exam should say “the right knee is not swollen, red or tender, and the range of motion is full” rather than “the right knee is normal.”. Use exact medical terminology in your differential diagnosis: For example, rather than saying “pulled muscle”, you should say “muscle strain”.
ALWAYS list MORE than 1 possible diagnosis. You should have at least 2, ideally 3, possible diagnoses in your differential. Your differential is critical for your clinical reasoning grade. 2 independent clinician raters will rate your note; they will not see your video or the SP ratings. Follow these rules for your differential:. Only list the most likely diagnoses based on the data that you have obtained.
List the possible diagnoses in order of likelihood, with the most likely diagnosis listed first. For each diagnosis that you provide, add at least 1 element from the history and physical to support the diagnosis. This element can be a pertinent positive or negative. It is preferable to have more than one supportive element listed. Copy and paste supporting arguments from the history and physical exam sections whenever you can in order to save time.
You will lose points if you list improbable diagnoses, if you do not provide supporting evidence (pertinent positives and negatives) and if you do not list your diagnoses in order of likelihood. At the end of your note, you will need to list the diagnostic tests that you recommend. Make sure these directly address your differential. Do not order unnecessary tests that you cannot justify.
Do not order invasive or expensive tests if you can achieve the diagnosis with a less invasive and/or less expensive test. If you think a rectal, pelvic, inguinal hernia, genitourinary, female breast, or corneal reflex examination would have been indicated in the encounter, list them in the test section. If you think no diagnostic studies are necessary, write 'No studies indicated' rather than leaving that section blank. Do not include treatment, consultations, or referrals in your plan. A few final tips. As a part of your study and preparation, View the orientation video available at the USMLE website.
View it more than once. Thoroughly review the book. This is consistently rated by successful UICCOM students as the best tool for effective preparation for the exam.
Copies are available in the counseling center. Use the to practice with the actual note template you will use on exam day.
Once the end of patient encounter announcement is made, STOP engaging the patient completely. If you don’t, this may be considered irregular behavior, will be reported to the USMLE, and could jeopardize your continued participation in the USMLE program. Once the end of note announcement is made, take your hands off the keyboard (or put your pen down in case you are writing your note, which may happen occasionally in case of technology malfunction). Continuing to write may be considered irregular behavior, will be reported to the USMLE, and could jeopardize your continued participation in the USMLE program.
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. In addition, view of the Primum Computer-based Case Simulations (CCS) examination. (Use Internet Explorer or another Flash-enabled browser to open.). Download the, which includes practice CCS cases. Read the to learn more about the Primum experience. Review the links below, which provide feedback on diagnostic and management steps for the sample Step 3 Computer-Based Case Simulations. These also appear at the end of the practice cases.
The CCS database contains thousands of possible tests and treatments. Therefore, it is not feasible to list every action that might affect an examinee's score. The descriptions are meant to serve as examples of actions that would add to, subtract from, or have no effect on an examinee's score for each case. Orientation Feedback for Tension Pneumothorax In evaluating case performance, the domains of diagnosis (including physical examination and appropriate diagnostic tests), therapy, monitoring, timing, sequencing, and location are considered.
In this case, a 65-year-old man is brought to the emergency department by ambulance because of acute chest pain and respiratory distress. Initially the presentation and reason for visit suggest a broad differential diagnosis, but the limited available history narrows the differential. The patient had an acute onset of right-sided chest pain 10 minutes before the ambulance arrived. He rates the pain as an 8 on a 10-point scale.
The pain is excruciating, sharp, and increases with respiration. The patient appears pale and in marked respiratory distress. He is moaning and holding his hands over the right side of his chest. Vital signs show tachypnea, tachycardia, and low blood pressure. Physical examination shows no breath sounds; there is tracheal deviation, jugular venous distention, hyperresonance to percussion on the right side of the chest, faint heart sounds, and weak peripheral pulses. The skin is pale, cool, and diaphoretic.
The remainder of the physical examination is unremarkable. The patient's illness, at this point, seems most consistent with an intrathoracic process. The computer-based case simulation database contains thousands of possible tests and treatments.
Therefore, it is not feasible to list every action that might affect an examinee's score. The following descriptions are meant to serve as examples of actions that would add to, subtract from, or have no effect on an examinee's score for this case. Timely diagnosis and management are essential in this case. An optimal, efficient diagnostic approach would include quickly performing a targeted physical examination that includes chest/lung and cardiovascular examination, cardiac monitoring, and assessing oxygen saturation by pulse oximetry. Treatment should be initiated immediately before the patient’s condition worsens. Ordering anything that might delay treatment (eg, a 12 lead ECG, arterial blood gases, or a portable chest x-ray) would be suboptimal in this case if ordered before the patient’s condition is stabilized.
As soon as the absent breath sounds and exam findings consistent with tension pneumothorax are discovered, optimal treatment would include performing a needle thoracostomy for decompression followed by a chest tube insertion for lung reexpansion. A chest x-ray should be ordered to confirm appropriate tube placement and lung reexpansion. The patient’s blood pressure and respiratory rate should be closely monitored until the patient’s condition has stabilized.
Examples of additional tests, treatments, or actions that could be ordered but would be neither useful nor harmful to the patient include:. Bronchodilators. Complete blood count. Electrolytes. Analgesics. Intravenous fluids Examples of suboptimal or poor management would include failure to examine the chest, admission before treatment, failure to order a chest x-ray after inserting the chest tube and/or needle thoracostomy, delay in treatment to reexpand the lung, or absence of treatment.
In this acute presentation, timing is critically important. An optimal approach would include completing the above diagnostic and management actions as quickly as possible. Delaying diagnosis or treatment and pursuing alternative diagnoses with tests such as a lung scan will waste valuable time and could be harmful or even fatal to the patient.
Other examples of treatments that would waste time, subject the patient to unnecessary discomfort or risk, and add no real benefit to this patient include:. CT before lung reexpansion.
Intubation. Pulmonary function testing. Thrombolytic therapy. Orientation Feedback for Rheumatoid Arthritis In evaluating case performance, the domains of diagnosis (including physical examination and appropriate diagnostic tests), therapy, monitoring, timing, sequencing, and location are considered. In this case, a 32-year-old woman comes to the office because of knee pain and swelling. From the chief complaint, the differential diagnosis is broad. It includes osteoarthritis, infectious arthritis, rheumatoid arthritis, systemic lupus erythematosus (SLE), gout, and psoriatic arthritis.
The comprehensive history, however, narrows the differential. The patient has experienced increasing fatigue and generalized weakness during the past 4 months. She developed generalized aches and morning joint stiffness during the past 8 weeks and, more recently, pain and intermittent swelling of both wrists, and of the proximal metacarpophalangeal joints, as well as bilateral knee swelling. These signs and symptoms are highly suggestive of a chronic systemic inflammatory process.
Physical examination shows bilateral swollen, warm, and tender wrist, proximal metacarpophalangeal, and knee joints, and bilateral knee effusions. Other physical findings are unremarkable. In the absence of other findings, the patient’s illness, at this point, seems most consistent with rheumatoid arthritis.
While the presence of certain clinical features is helpful in excluding other connective tissue diseases and osteoarthritis, further diagnostic evaluation is appropriate to confirm the presumptive diagnosis and establish the severity of the disease. The computer-based case simulation database contains thousands of possible tests and treatments. Therefore, it is not feasible to list every action that might affect an examinee's score. The following descriptions are meant to serve as examples of actions that would add to, subtract from, or have no effect on an examinee's score for this case.
An optimal, efficient approach to diagnosis would include performing an appropriate physical examination (including extremities/spine, chest/lung, cardiovascular, abdominal, skin, HEENT/neck, and lymph node examinations). A rheumatoid factor test or a cyclic citrullinated peptide antibody (Anti-CCP) test would support the diagnosis of rheumatoid arthritis. The diagnostic workup would also include a complete blood count, arthrocentesis with relevant synovial fluid studies (cell count, crystals, and bacterial culture), an antinuclear antibody assay, and an erythrocyte sedimentation rate or C-reactive protein test. These tests serve to assess the severity of the disease and consider the likelihood of SLE, gout, an infectious process, or reactive arthritis.
In addition, joint x-rays would provide a baseline assessment. In adult patients, an optimal approach to treatment would focus on relieving pain, decreasing inflammation, preventing or slowing joint damage, and improving function.
It is important to manage the acute phase of the disease and to address the long-term care of the patient in this case. Optimal treatment would include a combination of a nonsteroidal anti-inflammatory drug (NSAID) or corticosteroid with a disease-modifying antirheumatic drug (DMARD) for comprehensive therapeutic treatment. Administration of a DMARD, eg, methotrexate or etanercept, prevents or slows joint damage, and improves joint function. An NSAID or corticosteroid relieves pain and decreases inflammation essential to provide interim symptom relief while the selected DMARD takes effect.
To prevent deformity and loss of joint function, the patient would be advised to exercise appropriately. Or, a referral would be made for physical or occupational therapy. In this case simulation, when NSAID or corticosteroid treatment is initiated, the patient regularly reports both joint and systemic improvements.
Therefore, ordering a rheumatology consult or additional monitoring is appropriate but optional during the time frame of this simulation. Examples of additional tests and treatments that could be ordered but would be neither useful nor harmful to the patient include:. Chlamydia trachomatis tests. Neisseria gonorrhoeae tests. Antibody, anti-single-stranded DNA.
Thyroid studies. Urinalysis. Uric acid, serum Examples of suboptimal management of this case would include delay in diagnosis or treatment, or treatment with NSAIDS or corticosteroids alone. Treatment with salicylates would also be considered suboptimal management in this case. Although they would temporarily relieve pain when administered in high doses, there are other agents with fewer adverse effects that would be better treatment options. Examples of poor management would include failure to order any physical examination or failure to treat rheumatoid arthritis.
With the availability of effective treatment for rheumatoid arthritis and concerns about opioid addiction, narcotic analgesics should have a limited role in treatment. Examples of invasive tests that would subject the patient to unnecessary discomfort or risk and add no useful information include:.
Arthroscopy. Synovial biopsy While many case scenarios run for a relatively short period of simulated time, a matter of hours or days, this scenario runs for a longer period of time, weeks. This illustrates the importance of allowing sufficient time for the patient to respond to treatment and emphasizes monitoring and long-term management. Orientation Feedback for Ascending Aortic Dissection In evaluating case performance, the domains of diagnosis (including physical examination and appropriate diagnostic tests), therapy, monitoring, timing, sequencing, and location are considered. In this case, a 65-year-old woman comes to the emergency department because of chest pain. From the chief complaint, the differential diagnosis is broad; however, the comprehensive history narrows the differential. The patient is experiencing sharp, left-sided chest pain that radiates to her left jaw and to her back.
The pain began abruptly 45 minutes before the patient came to the emergency department. She is now short of breath and mildly nauseated. She has a history of hypertension for the past 5 years that is being appropriately treated with medication. There is no history of any previous episodes of chest pain either at rest or on exertion. The absence of fever, chills, cough, or pleural rub suggests that the problem is not an infectious pulmonary process. Physical examination shows hypertension and tachycardia with bounding central and peripheral pulses. The patient is anxious, diaphoretic, and in severe distress from chest pain.
Cardiovascular examination reveals a prominent and sustained apical impulse, and an indistinct S2 with S4 audible at the apex, and a grade 2/6 diastolic decrescendo murmur heard best at the right sternal border. HEENT/neck examination shows grade II arteriovenous nicking on funduscopic examination. The remainder of the physical examination is unremarkable.
The patient’s illness, at this point, would seem most consistent with a coronary or aortic abnormality with associated aortic regurgitation. In this case, the sudden onset of radiating chest pain along with the bounding pulses, widened pulse pressure, aortic murmur, and long history of hypertension are highly suggestive of the diagnosis of ascending aortic dissection.
The computer-based case simulation database contains thousands of possible tests and treatments. Therefore, it is not feasible to list every action that might affect an examinee's score. The following descriptions are meant to serve as examples of actions that would add to, subtract from, or have no effect on an examinee's score for this case. An optimal, efficient approach would include performing a targeted physical examination (including cardiovascular, chest/lung, and neurologic/psychiatric examinations), ordering a 12 lead electrocardiography (ECG), and a portable chest x-ray.
Optimal medical therapy would include stabilizing the patient with intravenous (IV) medications to lower both blood pressure and heart rate. Suboptimal treatment would include other antihypertensive agents. Lastly, IV narcotic analgesic administration to alleviate pain is important. The patient's cardiovascular status should be monitored with a cardiac monitor or by ordering repeat vital signs. Some measure of oxygen saturation is also indicated. Once stable, some form of chest imaging that would assess for an aortic dissection (including computed tomography (CT) of the chest with contrast, cardiac computed tomography angiography (CTA) with contrast, echocardiography, transesophageal echocardiography (TEE), magnetic resonance imaging (MRI) of the chest, or cardiac MRI with gadolinium) is needed. The diagnostic workup should also include blood tests for serum creatinine (basic metabolic profile or complete metabolic profile) to assess kidney function, electrolytes to check sodium and potassium concentrations, a complete blood count (CBC) to look for signs of anemia, serum creatine kinase or serum troponin I (cardiac enzymes) to rule out myocardial compromise, and a blood group and crossmatch.
Once the ascending aortic dissection is discovered and aortic root involvement confirmed, optimal treatment should include open heart surgery, endovascular aortic aneurysm repair (EVAR), thoracotomy or cardiothoracic surgery, or general surgery consult. In this acute presentation, timing is critically important.
An optimal approach would include completing the above diagnostic and management actions as quickly as possible (ie, during the first 2 hours of simulated time). Examples of additional tests, treatments, or actions that could be ordered but would be neither useful nor harmful to the patient include:. Admitting the patient to the inpatient ward or intensive care unit.
Antibiotics Suboptimal management of this case would include ordering additional physical examination components that would add no relevant information, administering an IV antihypertensive without a beta blocker, neglecting to order indicated blood tests, or a delay in diagnosis or treatment. It would be suboptimal to order anything unnecessary that would waste time, even if the test or procedure were not invasive or risky (eg, lung scan). Examples of poor management would include failure to order any physical examination, failure to order an imaging study that would reveal the dissection, failure to administer an antihypertensive agent, or failure to order surgical intervention. Examples of invasive and noninvasive actions that would subject the patient to unnecessary discomfort or risk include:. Changing the location to the outpatient office or sending the patient home.
Chest tube. Exercise ECG. Heparin. Laparotomy. Needle thoracostomy. Stress echocardiography.
Thrombolytics. Warfarin. Orientation Feedback for Asthma In evaluating case performance, the domains of diagnosis (including physical examination and appropriate diagnostic tests), therapy, monitoring, timing, sequencing, and location are considered. In this case, a 4-year-old boy is brought to the office because of increasing shortness of breath during the past 3 days. From the chief complaint, the differential diagnosis is broad; however, the comprehensive history narrows it. The patient has been wheezing and has a cough that has been worsening. The mother says that the wheezing seems to get worse after the patient plays outside but resolves shortly after he comes inside.
The patient has a history of frequent episodes of “wheezy bronchitis” and ear infections. When the patient was 2 years old, he was hospitalized for 1 week for similar symptoms and treated with intravenous antibiotics and oxygen.
At age 18 months, the patient had pressure equalizing tubes inserted. The patient also has a history of allergy to pollen and atopic dermatitis. Physical examination shows slight tachycardia. Chest/lung examination reveals bilateral, mild, intercostal retractions, and bilateral expiratory wheezes with prolonged expiratory phase, and no crackles.
HEENT/neck examination shows pale, boggy, edematous nasal mucosa without nasal flaring. Skin examination reveals dry, scaly patches in the antecubital areas.
The remainder of the physical examination is unremarkable. The patient's illness, at this point, would seem most consistent with an obstructive pulmonary disease process.
In this case, the increased coughing and wheezing, as well as the history of frequent respiratory and ear infections, are highly suggestive of the diagnosis of asthma. The computer-based case simulation database contains thousands of possible tests and treatments. Therefore, it is not feasible to list every action that might affect an examinee's score. The following descriptions are meant to serve as examples of actions that would add to, subtract from, or have no effect on an examinee's score for this case. An optimal, efficient approach would include performing a targeted physical examination (including HEENT/neck, chest/lung, cardiovascular, and abdominal examinations) and addressing oxygen status by ordering pulse oximetry or oxygen therapy.
Treating the patient’s respiratory distress with optimal inhalation bronchodilators (such as albuterol or levalbuterol), as well as optimal oral (PO) steroids, is essential. Optimal management should also include counseling the patient/family about asthma care and the side effects of medication.
Monitoring the patient’s respiratory status by ordering a chest/lung examination after treatment is also important. In this acute presentation, timing is important. An optimal approach would include completing the above diagnostic and management actions as quickly as possible (ie, during the first few hours of simulated time). Orientation Feedback for Diabetes with ketoacidosis; E.
Coli sepsis In evaluating case performance, the domains of diagnosis (including physical examination and appropriate diagnostic tests), therapy, monitoring, timing, sequencing, and location are considered. In this case, a 31-year-old woman is brought to the emergency department by her roommate because of lethargy, nausea, and vomiting. From the chief complaints, the differential diagnosis is broad and includes the many causes of acutely altered mental status. However, the comprehensive history narrows the possible differential diagnoses, making uncontrolled diabetes very likely. The patient has been experiencing nausea and vomiting for the past 24 hours and has been unable to eat during that time.
During the past hour, she has become drowsy and lethargic. She has a history of type 1 diabetes mellitus, for which she normally takes insulin multiple times daily. However, she has had no insulin during the past 24 hours. The patient’s roommate says that the patient experienced some chills yesterday. The patient appears drowsy, lethargic, and acutely ill. Physical examination reveals elevated temperature, tachypnea, tachycardia, and hypotension. Cardiovascular examination shows thready central and peripheral pulses.
Skin examination reveals poor turgor. HEENT/neck examination shows dry mucous membranes.
Abdominal examination reveals diffuse mild tenderness without guarding, rebound, or masses. Neurologic/psychiatric examination shows that the patient is lethargic but oriented. Taken together, the history and physical examination findings support the initial impression of complications of type 1 diabetes mellitus. In this particular patient, the history of type 1 diabetes mellitus presenting with prolonged nausea and vomiting and lethargy and drowsiness, combined with the physical examination findings of fever, thready pulses, tachycardia, signs of dehydration, and diffuse abdominal tenderness are highly suggestive of the diagnosis of diabetic ketoacidosis due to infection and inadequate insulin.
The computer-based case simulation database contains thousands of possible tests and treatments. Therefore, it is not feasible to list every action that might affect an examinee's score. The following descriptions are meant to serve as examples of actions that would add to, subtract from, or have no effect on an examinee's score for this case. An optimal, efficient approach would include performing a targeted physical examination (including chest/lung, cardiovascular, abdominal, and neurologic/psychiatric examinations), and ordering a serum glucose test using a glucometer and a urinalysis or complete blood count (CBC) to check for signs of infection. Stabilizing the patient with optimal intravenous (IV) fluids (eg, Lactated Ringer solution or normal saline solution) to improve hydration, and treating the patient empirically with a broad-spectrum IV or intramuscular (IM) antibiotic to cover the most likely sources of infection are important.
Once the serum glucose result is obtained, starting IV insulin to treat the hyperglycemia is critical. The patient’s cardiovascular status should be monitored by ordering repeat vital signs or by changing the patient’s location to the inpatient unit or intensive care unit. The diagnostic workup should also include arterial blood gas analysis to assess acidosis, bacterial blood culture to identify the organism before administering empiric antibiotics, and serum electrolyte measurements (ie, potassium) to assess the severity of dehydration.
Serum creatinine or urea nitrogen measurements (basic metabolic profile or complete metabolic profile) to assess kidney function are indicated. Continued monitoring of the patient’s serum glucose, electrolytes, particularly potassium, and arterial blood pH after treatment is also important. In this acute presentation, timing is critically important. An optimal approach would include completing the above diagnostic and management actions as quickly as possible (ie, during the first hour of simulated time). Orientation Feedback for Eclampsia In evaluating case performance, the domains of diagnosis (including physical examination and appropriate diagnostic tests), therapy, monitoring, timing, sequencing, and location are considered.
In this case, a 25-year-old woman at 38 weeks’ gestation comes to the emergency department after suffering a seizure with loss of consciousness about 10 minutes earlier. From the chief complaint, the differential diagnosis is broad; however, the comprehensive history narrows it. The patient is gravida 1, para 0, and has been receiving routine prenatal care. The pregnancy has been uncomplicated so far. She has had a severe headache for the past 3 days, and her feet have appeared swollen during the past 2 to 3 weeks. She has no previous history of seizures, and there is no history of hypertension or renal or neurologic disease.
The patient is conscious but appears confused. Physical examination shows tachycardia, a low-grade fever, and elevated blood pressure. Cardiovascular examination shows a loud S4 and bounding central and peripheral pulses. There is a grade 2/6 systolic ejection murmur at the left sternal border without radiation.
There is marked vasospasm on funduscopic examination with normal disc margins and a minor tongue laceration. Abdominal examination shows a gravid uterus with a fundal height of 37 cm. Estimated fetal weight is 2700 g (6 lb).
The fetus is cephalic by palpation with a fetal heart rate of 144 beats/min. Genital examination reveals an edematous vulva. The cervix is dilated to 1 cm and 50% effaced.
Extremities/spine examination shows 4+ pitting edema in both lower extremities to the midthigh region. Neurologic/psychiatric examination shows that the patient is conscious but oriented to person and place only. Deep tendon reflexes are 4+ with bilateral clonus at the ankles.
The remainder of the physical examination is unremarkable. The patient's illness, at this point, would seem most consistent with a neurologic or cardiovascular abnormality, possibly pregnancy-associated. In this pregnant patient, the new onset of seizure, elevated blood pressure, lower extremity edema, and hyperactive reflexes are highly suggestive of the diagnosis of eclampsia. The computer-based case simulation database contains thousands of possible tests and treatments. Therefore, it is not feasible to list every action that might affect an examinee's score. The following descriptions are meant to serve as examples of actions that would add to, subtract from, or have no effect on an examinee's score for this case. An optimal, efficient approach would include performing a targeted physical examination (including skin, HEENT/neck, chest/lung, cardiovascular, abdominal, genital, extremities, and neurologic/psychologic examinations) and ordering a complete blood count (CBC) to rule out hemolysis.
Stabilizing the patient with intravenous (IV) magnesium sulfate to prevent another seizure, plus an IV optimal antihypertensive (hydralazine or beta blockers) to reduce blood pressure, is important. Once the patient’s condition is stabilized, it is imperative to deliver the fetus either by stimulating contractions using optimal uterotonics, by performing a cesarean delivery, or by consulting obstetrics/gynecology. The fetal heart rate should be watched until delivery by ordering a fetal monitor. Some measure of the patient’s urine output is also indicated.
The diagnostic workup should also include a urinalysis and blood tests for the following: serum creatinine or urea nitrogen (basic metabolic profile or comprehensive metabolic profile) to assess kidney function; electrolytes to check sodium and potassium levels; liver enzymes; and platelet count to diagnose HELLP syndrome. In this acute presentation, timing is critically important. An optimal approach would include completing the above diagnostic and management actions as quickly as possible (ie, during the first hour of simulated time).
Examples of additional tests, treatments, or actions that could be ordered but would be neither useful nor harmful to the patient include:. Arterial blood gases or Pulse oximetry.
Fibrin breakdown products. Thrombin time, plasma Examples of poor management would include failure to order a neurologic/psychiatric examination, failure to administer an antihypertensive agent, failure to monitor the fetus or mother, or administering a suboptimal seizure medication (phenobarbital).
Examples of invasive and noninvasive actions that would subject the patient to unnecessary discomfort or risk, or would add no useful information to that available through safer or less invasive means, include:. Changing the location to the outpatient office or sending the patient home. Mifepristone PO. CT, abdomen/pelvis. Carboprost IM.
Alprostadil IV. Dilatation and curettage.
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